- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 4: Getting Ready to Bill Medicare
Identifying Payers Primary to Medicare
Information for All Providers
Table of Contents
Determine if Medicare is Primary Payer
All facilities that bill Medicare for services rendered to beneficiaries are required to determine if Medicare is the primary payer for those services.
- Fact: MSP Provisions require certain coverage to be billed before Medicare for a beneficiary’s services.
You can determine whether Medicare is the primary, secondary, or greater payer once you determine whether or not the beneficiary has other coverage. To determine whether or not the beneficiary has coverage other than Medicare, providers must conduct an MSP screening process during which you ask beneficiaries (or their representatives) questions concerning their most recent MSP status. Typically, this is done via a hard copy or electronic MSP questionnaire.
CMS developed a model MSP questionnaire providers can use. This model can be found in the CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1. If your facility chooses to use CMS’ model MSP questionnaire, please be aware that the questions were designed to be asked in sequence. If your facility chooses to use its own form, it should be compliant (have same content and intent as that of CMS’ model MSP questionnaire).
MSP Information Collection Requirements—Frequency
While the requirement to determine whether Medicare is the primary payer applies to all providers, CMS has issued explicit MSP information collection requirements for hospitals only with regard to the frequency of the administration of the MSP questionnaire. These instructions are found in CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Sections 20.1 and 20.2, and are discussed below in the section titled “Information for Hospitals Only.”
At this time, CMS has not issued explicit MSP information collection requirements for other provider types (other than hospitals) with regard to the frequency of the administration of the MSP questionnaire. However, we recommend that all providers follow the same frequency guidelines that CMS has issued for hospitals. It is in all providers’ best interest to collect MSP information as frequently as possible to ensure they are filing proper Medicare claims. If any provider fails to file correct and accurate claims with Medicare, Medicare can recover its payments and, in cases where an entity knowingly bills Medicare incorrectly, can even pursue civil monetary penalties or damages under the False Claims Act.
Retirement Dates
To determine the appropriate primary payer for a beneficiary’s services, it is important that providers collect the beneficiary’s, spouse’s and/or family member’s retirement date(s) as applicable. Collecting retirement dates is a part of the MSP screening process and the model MSP questionnaire is designed to capture such dates. Providers must report collected retirement dates on their Medicare claims using occurrence code 18 for the beneficiary’s retirement date and occurrence code 19 for the spouse’s retirement date.
Providers should also be aware of additional claim coding that must be reported on Medicare claim(s), when applicable, to let Medicare know the reason why Medicare is the primary payer. This includes condition codes 09, 10, 11, 28 and 29.
CMS’ Retirement Date Policy When Beneficiary/Spouse Cannot Recall
A particular challenge for all providers can be when the beneficiary cannot recall his/her own retirement date or that of their spouse.
CMS has explicit instructions for hospitals regarding the collection of retirement date(s) when the individual cannot recall the specific date(s). These instructions are found in CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.1. Because the information can be helpful to other provider types(other than hospitals) in their attempt to collect retirement dates, we recommend that other providers follow these instructions as well.
During your MSP screening process, when a beneficiary cannot recall his/her precise retirement date as it relates to coverage under a GHP as a policyholder or cannot recall the same information as it relates to his/her spouse, as applicable, hospitals must follow the policy below.
When a beneficiary cannot recall his/her retirement date but knows it occurred prior to his/her Medicare entitlement dates, as shown on his/her Medicare card, hospitals report his/her Medicare A entitlement date as the date of retirement. If the beneficiary is a dependent under his/her spouse's GHP and the spouse retired prior to the beneficiary's Medicare Part A entitlement date, hospitals report the beneficiary's Medicare entitlement date as his/her retirement date.
If the beneficiary worked beyond his/her Medicare A entitlement date, had coverage under a GHP during that time, and cannot recall his/her date of retirement but the hospital determines it has been at least five years since the beneficiary retired, the hospital enters the retirement date as five years retrospective to the date of admission (example, hospitals report the retirement date as January 4, 2010, if the date of admission is January 4, 2015). As applicable, the same procedure holds for a spouse who had retired at least five years prior to the date of the beneficiary's hospital admission.
If a beneficiary's (or spouse's, as applicable) retirement date occurred less than five years ago, the hospital must obtain the retirement date from appropriate informational sources; e.g., former employer or supplemental insurer.
Beneficiary MSP Information in Medicare's Records
Once providers collect MSP information from the beneficiary, it is important to compare that information with the MSP information in Medicare’s records, the CWF. The objective is for providers to submit claims containing the most current information regarding the beneficiary’s MSP status.
In certain situations, such as retirement, the retirement date is all that is needed to update the GHP MSP record in Medicare’s records (MSP working aged record or MSP disabled record). This is why it is important to report retirement dates on your claims as explained above.
Providers may access MSP information via the CWF (HIQA or HIQH transactions) in the FISS/DDE, or providers who use NGSConnex can use it to access the same information. Providers can use CMS’ HETS to access the information or finally, providers can dial into our IVR system.
At the provider’s discretion, this MSP information may be reviewed at any time during the admission or the billing process. However, it must be viewed before a bill is submitted to Medicare, and should ideally be reviewed before the beneficiary leaves your facility.
Note: In situations, in which a provider determines that Medicare’s MSP record must be updated, refer to the “Medicare Secondary Payer” section of this guide and review the Benefits Coordination and Recovery Center (BCRC) information.
Information for Hospitals Only (All Providers Please Read)
Although CMS issued the below information for hospitals, we recommend that all providers follow the same guidelines.
Frequency of MSP Information Collection
Hospitals should conduct the MSP screening process for every inpatient admission, outpatient encounter or start of care. However, CMS has specific frequency requirements for certain services that hospitals render.
Policy for Hospital Reference Laboratory Services
Hospitals are not required to collect MSP information in order to bill Medicare for reference laboratory services. Reference laboratory services are clinical laboratory diagnostic tests (or the interpretation of such tests, or both) furnished without a face-to-face encounter between the individual entitled to benefits under part A or enrolled under part B, or both, and the hospital involved and in which the hospital submits a claim only for such test or interpretation. This policy, however, will not be a valid defense to Medicare’s right to recover when a mistaken payment situation is later found to exist. If there is a face-to-face encounter with the beneficiary, then MSP information must be collected for the lab service.
Policy for Recurring Hospital Outpatient Services
Hospitals are required to collect MSP information for hospital outpatient recurring services. A Medicare beneficiary is considered to be receiving recurring services if he/she receives identical services and treatments on an outpatient basis more than once within a billing cycle. Following the initial collection, the MSP information should be verified once every 90 days. If the MSP information collected by the hospital is not older than 90 calendar days from the date the service was rendered, then that information may be used by the hospital to bill Medicare for recurring outpatient services. This policy, however, will not be a valid defense to Medicare’s right to recover when a mistaken payment situation is later found to exist. Hospitals must be able to demonstrate that they collected MSP information from the beneficiary or his/her representative, which is not older than 90 days, when submitting bills for their Medicare patients. Acceptable documentation may be the last (dated) update of the MSP information, either electronic or hardcopy.
Policy for Medicare Advantage Organization Members
If the beneficiary is a member of a MAO plan, hospitals are not required to ask the MSP questions or to collect, maintain, or report this information. However, this should be done if the MAO plan requires it.
Revised 1/2021